Bodily Injury Claims: Study 4

Spine, Head and Nervous System

Spinal Column:

Spinal column (vertebral column) is made up of 33 bones called vertebrae
Vertebrae are divided into 5 groups

Seven cervical vertebrae in the neck
Twelve thoracic vertebrae in the chest area
Five lumbar vertebrae in the mid to lower back
Five sacral vertebrae in the lower back (these are fused in adults)
Four coccygeal vertebrae also known as the coccyx or tail bone (these are fused)

Atlas is the top vertebra (first cervical vertebra) and supports the skull
Spine is united with the pelvis at the sacral vertebrae
Each vertebra has an opening called a vertebral foramen (pl. foramina)
Foramina make a vertical passageway (vertebral canal) through which the spinal cord runs
Vertebrae have three bony extensions or processes

A single fin-like spinous process
Two transverse processes which are wing-like

Each vertebra is separated by a doughnut-shaped intervertebral disc which acts as a shock absorber
CT (Computerized Tomography) scans and MRI (Magnetic Resonance Imaging) scans are commonly used to provide images of damaged disc structure and distorted spinal nerves
Intervertebral Disc Injury:

When forces are exerted on the cervical or lumbar area of the spine, it is possible that the intervertebral disc will crack or rupture (herniated disc syndrome)
If the spaces collapse the vertebrae may impinge on the nerves causing pain to radiate down the arms or legs, depending on the location of the injury
Usually treatment consists of rest, massage, graduated exercise, heat in various forms, bracing, and drugs to relieve pain and relax muscles

Spinal Fusion:

Spinal fusion is a type of bone graft
Fragment of bone is taken from the pelvis and used to reinforce or strengthen the spine
Two or more vertebrae are fused and the multiple joint is reduced to a single joint
Spinal fusion is not a complete cure even when union does occur
After a period of 5 – 6 years, depending on the patient’s activity, a situation can develop called pseudoarthrosis which is a week or unsatisfactory union known as a false joint
By fusing two vertebrae, the area above or below the site is subjected to a greater degree of activity, and the disc above or below the fusion may then require further surgical intervention
The entire spine could be fused in an attempt to correct one situation after another

Subluxation:

Subluxation of a vertebra is a common result of a flexion-extension injury
Kyphosis is the exaggerated increase in the thoracic curve
Lordosis is the increased forward curve in the lumbar area
Scoliosis refers to a lateral curvature of the spine

Backache:

Can be a symptom of disease or trauma
Diseases of the spine include tuberculosis, Osteomyelitis, rheumatoid arthritis, and cancer
Sometimes mental (psychogenic) factors cause back pain
Treatment has traditionally been rest, massage, graduated exercise, heat in various forms, bracing, and drugs to relieve pain and relax muscles
Studies involving strains and sprains suggest that patients should return to some form of activity as soon as possible

Fractures:

Cervical and lumbar areas are more likely to be damaged by strain or sprain
The other spinal regions, being more rigid and having greater protection, are more subject to fracture
Cervical Spine (neck):

Fractures of the cervical spine are the most serious injury involving the spinal column because of its relationship to the spinal cord
Surgery and traction are used to realign the bone fracture

Thoracic and Lumbar Spine (upper and lower back):

Compression fractures do not usually involve injury to the spinal cord
These injuries usually resolve themselves with treatment in a period of 3- 6 months without any lasting permanent disability

Coccyx (tailbone):

Fall on the coccyx is extremely painful but the treatment is very conservative
Analgesics (painkillers) are prescribed
This fracture is never associated with injury to the spinal cord
If pain in this particular area persists a coccygectomy is performed

This is where the coccyx is removed surgically

The coccyx has no functional value

Transverse Processes and Spinal Process (fins & wings):

Minimal amount of treatment required
Disability is painful, but no permanent injury or disability results
Not considered to be “true” fractures and should not be confused with actual fractures of vertebrae

Head:

Teeth:

Primary teeth appear at 6 to 24 months of age

10 upper and 10 lower teeth at this time

Permanent teeth appear at age 6 or 7

16 upper and 16 lower permanent teeth

Primary teeth are place holders for permanent teeth
The mouth contains a total of 32 permanent teeth divided into 4 groups:

8 incisors at the front
4 canines flanking the incisors
8 bicuspids behind the canines
12 molars at the rear of the jaw

Teeth are composed of 4 types of tissue:

Enamel
Dentine
Dental Pulp
Cementum

Dental injuries are seldom encountered without facial trauma
To assess tooth damage it is important to know if the tooth is vital
Vital tooth has internal strength because the pulp and dentinal tissue are alive
Non-Vital tooth conversely has had its nerves and blood vessels (pulp) destroyed or removed
If a tooth is accidentally knocked out it can be reimplanted if action is taken promptly
A broken tooth cannot be reimplanted
Periodontitis:

is a disease of the connective tissue, bone and gum surrounding and supporting the teeth
It causes inflammation of the gums (gingivitis) and loss of bone tissue around the teeth

In the case of a jaw fracture:

Lose the ability to chew
Could cause Tempromandibular Joint (TMJ) dysfunction which is when the jaw joint has been damaged, causing muscular discomfort, loss of hearing and tinnitus (roaring or ringing in the ears)
Diagnosis of TMJ dysfunction tends to be controversial within dental profession and should be carefully investigated

Artificial teeth:

Prosthesis is any appliance designed to replace a missing body part with an artificial one
Artificial teeth and bridgework would fall into this category
Careful investigation and dental examination is necessary to determine what these items consisted of and their relative quality prior to the accident
Depreciation may be applicable

Primary teeth injuries can affect the development of permanent teeth
Dental claims can be exaggerated

Patient may have needed extensive treatment prior to the injury

Prior x-rays should be compared to current x-rays, and the assistance of a dentist or dental surgeon should be sought early

Ears:

The ear has 2 main functions:

Provides sense of hearing
Maintains the body’s sense of balance

Consists of 3 principal parts:

Outer ear or pinna is the visible outer fleshy protuberance forming the auricle plus the opening and the external auditory canal
Middle ear or tympanic cavity lies between the eardrum or tympanic membrane and a thin partition of bone which separates it from the inner ear

Three tiny connected bones, the auditory ossicles, move within the middle ear and are essential for the transfer of sound from the outer ear to the inner ear
Auditory ossicles are composed of:

Malleus: is attached to the eardrum
Incus: connects the malleus to the inner bone called the stapes
Stapes: is attached to the inner ear

Inner Ear consists of a number of fluid-filled passageways called the labyrinth and is located partly in the temporal bone of the skull

3 main parts of the inner ear are:

Vestibule
Semicircular canals
Cochlea

The three semicircular canals, filled with fluid, provide a sense of balance
Cochlea contains the spiral-shaped “organ of Corti” – special sensory receptors for hearing

Injury to external ear:

Healing is usually rapid in clean wounds
Very serious injuries may cause three to four weeks total disability

Burst eardrum:

Severe blow may burst the tympanic membrane
Severe pain and shock will result accompanied usually by slight bleeding, tinnitus, and sometimes nausea and dizziness
Damage to the tympanic membrane often results in some hearing impairment

Measuring hearing loss:

Loss of hearing is measured in units called decibels
0 Decibels is the point at which sound first becomes audible
20 decibels is a whisper
60 decibels is a normal talking voice
90 decibels is a disturbingly loud noise, such as an automobile horn

Eyes:

Eyelids consist of muscles that regulate the exposure of the eyeball to light

Also clean and lubricate the surface of the eyeball

Lacrimal glands are located under the upper eyelid and produce tears
Lacrimal ducts lead from the inner corners of the eye to the nose and act as drains for the eyes
Eyeball is located in a bony socket known as the orbital cavity of the skull
Sclera is the tough white membrane that sheaths most of the eyeball
Cornea is the transparent membrane at the front and centre of the eyeball that refracts light to the rear of the eye
Conjuctiva is the smooth transparent layer of tissue that protects the cornea
Aqueous humor is the clear fluid that fills the area between the cornea and the lens
Lens is behind the iris
Iris is the thin circle of coloured tissue behind the cornea whit a hole in the centre called the pupil which changes size to regulate the amount of light entering the eye
Shape of the pupil is controlled by the ciliary muscle which allows the eye to focus
Retina lines the inner surface of the eyeball and contains the nerve cells that are sensitive to light

It is attached to an underlying black pigmented vascular layer called the choroid

Optic nerve transfers nerve impulses from the retina to the brain

It is located at the back of the eyeball opposite the cornea

Vitreous humor is the jelly-like fluid that fills the eyeball cavity
Abrasions to the eye are usually not serious and are treated with special drops or ointments to prevent septic inflammation
If inflammation is not treated promptly a corneal ulcer may result
Scars from the healing wound can cause loss of vision
Injury to Conjunctiva:

Antibiotics are used to prevent infection
Daily examination of the good eye is necessary, since the good eye may develop sympathetic ophthalmia in sympathy with the injured eye
Good eye adopts the pathology of the injured eye
May be necessary to remove the injured eye to prevent this

Skull:

The skull is composed of the cranial bones and the bones of the face
Cranium includes 8 bones that form the dome to encase the brain:

Occipital bone
2 parietal bones
2 temporal bones
Sphenoid bone
Ethmoid bone
Frontal bone

Fractures:

Severity of skull fractures is gauged by the amount of injury to the brain and the nerves which enter and leave the brain
4 basic types of fractures to the skull:

Basal Fracture:

most common
lower part of the skull where it connects with spinal column
symptoms include bleeding from ears and hearing impairment
tinnitus may be present
Possibility of hearing loss and permanent ringing of the ears

Linear Fracture:

No depression of the skull
Does not cause significant damage or changes to individual
Fracture may involve blood vessels which will cause bleeding outside brain covering (Extradural haemorrhage)

Depressed Fracture:

Involves bone fragments driven into intracranial cavity
Very serious in that they may lacerate membrane covering brain or brain itself
Could result in serious permanent impairment

Compound Fracture:

Skull opens up to exterior of scalp
Susceptible to infection
May result in permanent disability
May cause loss of smell, loss of vision, and possibility of brain abscess when the fracture involves the paranasal sinuses

Symptoms may include headache, dizzy spells, visual and speech disturbances, mental or personality changes, temporary or permanent forms of paralysis, and loss of special senses such as taste, hearing or sight
Should spinal fluid drain through the fracture site meningitis can develop
Epilepsy may result

Facial Bones:

Some important facial bones:

Nasals: make the bridge of the nose
Lacrimals: are between the eyes
Malars: are the cheek bones
Maxillae: upper jaw bones
Mandible: lower jaw bone

Hyoid bone: is situated at the root of the tongue and doesn’t connect with any other bones
Most common type of injury to the face is a fracture of the nasal bones

Usually the person can return to work within 5-10 days

2nd most common type of injury is mandible (lower jaw)

Usually treated by a dentist, oral surgeon, or plastic surgeon
Wiring of teeth is sometimes required
Chewing is impossible (liquid diet necessary)

Nervous System:

Nervous system is the electro-chemical information pathway of the body
Can be divided into 2 main parts:

Central Nervous System

Consists of brain and spinal cord
Unable to repair itself

Peripheral Nervous System

Includes all other nerve elements
Able to repair itself

Brain:

Consists of nerve cells called neurons, supporting cells called glial cells and blood vessels
Continues to grow in size until 15 years old
Divided into three main parts:

Forebrain: Divided into 4 main parts

2 cerebral hemispheres: logic and creativity
Thalamus: sensory information
Hypothalamus: links nervous system and releases hormones
Limbic system: memory and instinctive emotions

Midbrain: first part of brain stem where sensory and motor nerve fibres cross to supply opposite sides of the body
Hindbrain: located at back and base of skull and includes cerebellum which is involved in coordination of movement and pons, where nerve fibres interconnect

Brain is contained in 3 protective membranes or meninges known as:

Dura (located next to skull)
Arachnoid (beneath the dura)
Pia Mater (encases brain and contains blood vessels)

Terms frequently used to identify general areas of the brain:

Frontal Lobe: area containing the cerebrum at front of skull
Parietal Lobe: situated in upper back part of skull
Occipital Lobe: at back of skull, housing part of brain involved with sight
Temporal Lobes: located at sides of skull, contain part of brain responsible for memory

Damage to Cells:

Brain cells do not renew themselves
Sometimes undamaged cells are able to take over part of the function of the destroyed cells
Brain emits electrical waves which can be measured by electroencephalogram (EEG)

This instrument helps doctors diagnose brain disorders

Quantified electroencephalography (QEEG) is new method used to analyze brain activity

Closed-head Injury:

Brain injury can occur without physical impact to head
Whiplash victim with prolonged cognitive complaints may have brain damage from acceleration flexion-extension action
Symptoms such as loss of consciousness, temporary amnesia, a state of confusion, dizziness and vomiting are signs of brain injury
Symptoms sometimes do not manifest themselves until several days or even weeks after the accident
Sometimes only a specific area of patient’s capabilities are affected

Can make it difficult to diagnose the injury

To judge severity of brain injury doctors use Glasgow Coma Scale

Patients answer questions to a standardized test and their responses are recorded
When patient is unconscious other tests are used to score results

Post traumatic amnesia, confusion and poor orientation are also factors to consider

If amnesia lasted only 5 minutes it is considered very mild
If it lasted 5 min – 1 hour considered mild
1 – 24 hours considered moderate
1-7 days considered severe
1-4 weeks very severe
Post-traumatic amnesia is divided into two categories:

Retrograde Amnesia: lose memory of events before injury
Anterograde Amnesia: lose memory of events after injury

Patient is kept in intensive care under close observation for 24 hours after consciousness is regained
Usually sleeping patient will be awakened every hour to make sure there is no intracranial haemorrhage (subdural haematoma) which may press on vital parts of the brain to cause paralysis or death
Failure to awaken signals need for immediate surgery by boring holes in skull to relieve brain pressure

Brain injuries often cause changes in patient’s cognitive, behavioral, and physical skills

Cognitive disabilities include disorientation, memory loss, inability to make decisions and loss of concentration. Language skills can also be affected
Behavior and personality symptoms commonly include apathy, impulsiveness, aggressiveness, anxiety, depression, indecision, indifference, drug and alcohol abuse
Physical symptoms can include poor balance, poor coordination, fatigue, headaches and dizziness

Concussion:

Violent jarring or blow to head causing brain to bounce against inside of skull
Blood vessels rupture permitting blood to escape building pressure on brain
Characterized by period of unconsciousness at time of injury
Symptoms include vomiting, dizziness and temporary loss of sensation or movement in particular area of the body
Ringing in ears may occur and also temporary blurring of vision
May cause memory loss of incidents immediately before accident and subsequent events for variable periods of time
Headaches are common and usually become less severe over time

Cerebral Contusions:

More serious and more severe than cerebral concussions
May result in prolonged period of unconsciousness or cause death
Swelling and bruising of brain may lead to intracranial pressure caused by subdural haematoma
Symptoms are transitory paralysis with motor weakness
More serious contusions will result in a dazed state
Consciousness and orientation with one’s surroundings will remain, but there will be gross inability to focus one’s attention and take action

Traumatic Psychosis:

Symptoms of psychotic impairment caused by physical injury to head are known as traumatic psychosis
Usual symptoms are delusions and hallucinations
3 major recognizable stages:

Patient is in a stupor or coma and does not respond to any feeding or nursing. This stage may last 3 or 4 days in serious cases
Patient is in a delirium exhibiting restless and noisy behavior. Incoherent and confused, sometimes violent.
Patient has partial or complete amnesia

Spinal Cord:

Extension of brain and part of central nervous system
Carries messages from brain to allow movement
Receives sensations from skin and transmits them to brain
Encased in meninges and filled with cerebrospinal fluid
If spinal cord is only partially damaged some sensation and movement may return

May take 6 months to 1 year to resolve

Injury:

Paraplegia results when lower extremities are involved and injured person can become quite mobile in a wheelchair
Quadriplegia results when spinal cord is severed within cervical area of spinal column

Majority of spinal injuries are caused by forcible and excessive flexion
Any actions that produce additional flexion should be avoided
Medical treatment for injury to spinal cord is palliative – it attempts to relieve the effects of the injury rather than to heal or cure
Extensive rehabilitation program must be implemented to teach patient to live with effects of injury

Definitions:

Discectomy: is the removal of a damaged intervertebral disc or part of it

Laminectomy: is the removal of part of a vertebra

Spinal Fusion: is the fusing or rigid joining together of two or more vertebrae

Sublexation: is the partial displacement of bone resulting in misalignment in the joint

Osteomyelitis: is an inflammation of bone caused by a pus producing organism. It is treated with antibiotics

Enamel: is a very hard material covering the crown or the exposed part of the tooth

Dentine: is the ivory material that makes up the body of the tooth

Dental Pulp: is soft tissue that fills the core of the tooth and contains the blood vessels and nerves

Cementum: is hard material covering the root

Septic Inflammation: is the reaction caused by the decomposition of microorganisms

Ophthalmia: is a severe inflammation of the eye

Sympathetic ophthalmia: is the inflammation of the uninjured eye and it usually involves the uveal tract

Extradural: means on the outside of the outer membrane of the brain

Meningitis: is the inflammation of the membranes that encase the brain and the spinal cord

Subdural Haematoma: is an abnormal collection of blood between the brain and the skull which exerts pressure on the brain, and causes the patient to lose consciousness, and may result in eventual paralysis

Paraplegia: is the paralysis of both legs and the lower part of the body caused by a spinal cord injury

Quadriplegia: is the paralysis of arms, legs, and most of the body trunk caused by a spinal cord injury

C32 Bodily Injury Claims

C32 Chapter 4 Bodily Injury Claims Study

Spine, Head and Nervous System

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